Physiotherapy in Ghana

I have procrastinated (yeah yeah I know..) in writing this post. I am nervous about portraying inaccurately or with bias, a hospital, department or health service that I don't fully understand. However I am writing to document and share my experience and here it is.

Like any service, physiotherapy is dictated by the needs of those it serves and by the resources that are available to it, and the physiotherapy department here (3 physiotherapists and a secretary) is meeting the needs of it's community in the best way it knows how to. However the staff are aware that this falls far short of what is really needed and a 'postcode lottery' doesn't even begin to describe the barriers to decent health care that many people face. Physiotherapy is only one example but in terms of accessibility and equality of provision it is probably fairly representative of most health care services.

Referrals are received from the hospital and local clinics. Patients may present to a doctor soon after an injury or onset of symptoms, or it could be days or weeks later. This is true for major traumas (such as open fractures or partial amputations) as for minor ones. The doctor may refer for physio or they may not. They often are not aware of what physiotherapy could offer, not a problem unique to Africa. The physiotherapy department itself does not have a waiting list: all patients are seen within a week of referral. This would be a fantastic situation at home - here however it simply reflects the gross under use of a department which is unable to reach the people that need its services.

The patients that are referred to physiotherapy present with many conditions common to us: a lot of stroke patients for example, though usually months or years down the line when neurological recovery is most unlikely and they are dealing with the effects of previous poor management. They also have children from a local special needs school come to use the facilities for exercise. The school has no name other than 'school for the mentally retarded and handicapped' ! Many of these kids also have a physical disability - the two I have seen both had a hemiplegia but I have no idea about the others as none of them had databases, problem lists or goals. Or notes in fact.

There are also a lot of patients with musculoskeletal problems: arthritic joint pain, neck or low back pain - as we see at home. The causes and aggravating factors vary a bit though. You probably wouldn't see on an assessment at home: "patient reports pain when carrying water on her head". Most of the patients are outpatients, although (according to the book at least) there are between 1 and 6 patients a month treated as inpatients.

The actual treatments are, on the whole, aimed at symptomatic relief and the conditions usually are chronic - many patients are not referred until a long time after initial onset of symptoms. Commonly used treatment modalities are heat treatments and massage, gait and stair practice, carried out routinely (reassessment is less frequent than I am used to), many patients attending twice a week. Active exercises are also given - usually using pulleys and the gym equipment available. Only 60% of the population are literate and many don't speak English so my prowess in stick men diagrams which require no explanation is being pushed to the limit.

Function is addressed but often the physical and functional requirements of a task are not really broken down so compensatory mechanisms are practised until they become established. As it was put on my recent Bobath course "if you take something away, you have to give something back": these patients unfortunately are often struggling fruitlessly to obey a command which is impossible for them.

The problem for many people is distance - they may be required to travel long distances to attend physiotherapy and there is no alternative - physiotherapy is not offered in local centres and there is no community outreach. People who are fortunate enough to have wheelchairs at home usually do not bring them into the department as they have no means to transport them - they tend to be carried in from the taxi. The proportion of non ambulant patients is small - I imagine we just don't see the majority.

Facilities and staffing obviously present difficulties: ferrules on the whole are worn through, wheelchair brakes don't work, there are no specialist seating systems, standing frames, splints or basic materials. However the biggest need in this community is probably education. People don't understand their own health conditions, they don't know when to seek help or where to go; even within hospitals emrergencies are not treated with urgency and preventable morbidity (and mortality) is not prevented. Socially, a physical disability in childhood is seen as a curse on the family and usually the child is kept hidden away in the home. Last week an 8 year old girl, who is unable to sit or stand independently, was brought into the department - nobody in her community knew she existed and she was not known previously to the health service.

The Ghanian physios are lovely to work with: they are happy to answer my questions and ask for my advice and input. It is still a difficult line to tread though, being a volunteer and working within your own profession where decisions are made very differently and where sometimes you do not agree with the choice of treatment. I am given a lot of freedom to treat patients as I wish but I am mindful that my way of doing things will not necessarily transfer practically to another culture. Not would it be accepted easily or quickly. As we are all reminded on beginning the programme, I am not here to change the world, only to share experiences and promote understanding and respect across cultures.